Foot and ankle rehabilitation presents a special challenge for patients suffering from chronic pain.

One of the failures of foot and ankle rehabilitation for patients suffering from chronic conditions has been inadequate assessment and management of pain. Chronic conditions and the resultant pain need to be addressed in the rehabilitative process. A foot or ankle injury may be secondary to the chronic pain condition, or the result of the condition. Nevertheless, in the assessment of the overall condition of the patient’s health, or in the case of a patient diagnosed with a chronic condition, pain management then becomes an integral goal in the rehabilitative process.

Since January 2001, hospitals, outpatient clinics, and nursing homes accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) must follow a new standard that requires every patient’s pain be measured and managed regularly with pain considered as the fifth vital sign.1 It is a patient’s absolute right to have proper pain assessment and treatment. The best practice is to manage pain by addressing the cause and reassessing on a regular basis.

Pain assessment tools include visual analog scales (VAS) and faces scales, which measure pain intensity on a linear scale from 0 to 10; and the McGill Pain Questionaire (short form), which measures 11 sensory and four affective pain descriptors, and rates them on an intensity scale of 0 to 3 for quantitative information beyond the VAS.2 Another approach is to interview the patient or caregiver and develop a pain history by asking guiding questions about the location of the pain, what triggers the pain, frequency of the pain, and when the pain began 3 

Observing the reaction to palpation or repositioning during examination can provide important clues. Withdrawal, guarding, or moaning are obvious signs of pain. For consistency, use the same method of measuring pain each time. A majority of adults do not report pain verbally or cognitively but communicate through behaviors. Signs of pain may include body language, anxiety, and depression. Pain is an important feature of a leg ulcer, and unrelieved pain has detrimental effects on wound healing.

A survey of wound care professionals in 2000 showed that leg and burn wounds are the most painful because removing wound dressings causes considerable pain as products adhere to the wound, or the dressing dries out and wound cleansing produces significant pain.4 Significant pain is also reported by patients and caregivers for patients with pressure and diabetic ulcers. Krasner divided wound pain into three categories based on the frequency of occurrence: 1) noncyclic acute wound pain such as that associated with sharp debridement; 2) cyclic acute wound pain that recurs as a consequence of repeated treatment interventions such as dressing changes or repositioning; and 3) chronic wound pain that is persistent without manipulation, such as burning pain of the diabetic.5 

Physiologically noncyclic and cyclic wound pain originates from direct nerve stimulation of intact fibers (nociceptive pain). Mild nociceptive pain usually responds to treatment with anti-inflammatories. Moderate and severe nociceptive pain often requires increasing strengths of narcotic agents.6 

Pain from damaged nerve fibers (neuropathic pain) is due to nerve irritation and often responds to tricyclic antidepressants. Nerve damage pain, another more severe type of neuropathic pain, is usually described as shooting or stabbing. Antiepileptic agents have shown therapeutic benefit for this group.7 Neuropathic pain is often associated with diabetic wound pain.

Chronic wounds are contaminated with bacteria that become colonized in the tissues. When the bacterial burden increases, pain often occurs. Severe pain or tenderness within or around the wound may be an indicator of infection that can lead to deep tissue destruction. Tissue congestion (edema) creates tension and irritation of the intact nerve fibers, resulting in persistent wound pain.

Various Causes of Pain

Noncyclical acute wound pain or pain associated with debridement, especially sharp debridement, is reported to be severe, and efforts to relieve pain are required. Some clinical trials8 report statistically significant pain reduction when an eutectic mixture of local anesthetic (EMLA), such as lidocaine and prilocaine cream, is administered 30 to 45 minutes under an occlusive dressing prior to the debridement procedure. Skin should be monitored for irritation during this procedure.8 

For cyclic acute wound pain, dressings can relieve the persistent pain of venous leg ulceration. Dressings that can be removed without trauma and with less frequent changes make the changing process less painful. 

Recent attention has focused on wound adhesives and their effect on the adjacent skin surface. A study of wound adhesives showed that skin damage from adhesive dressings was related to the forces needed for removal. Hydrocolloids, for example, are designed to be left intact for several days. If they are removed immediately or shortly after application, the stickiness of the adhesive requires considerable force to remove and may tear the underlying skin and cause pain. A recent study showed that a new self-adherent, soft-silicone scar dressing required less peel force to remove, and caused less pain than several other dressings.9 

Chronic Wound Pain

Begin by addressing the underlying physiological cause of chronic pain. Reduce tissue edema and tension around venous ulcers by compression, and treat infection with antibiotics or Ultraviolet C light. For diabetics, modulate neuropathic pain with transcutaneous electrical nerve stimulation (TENS). TENS has long been used to treat chronic pain, and there is evidence that it can help diabetic pain.10, 11 TENS has the added benefit of increasing the local circulation needed for healing.12 

Positioning and orthotic devices can be valuable in reducing pressure on the wound and relieving pain. Warming therapy that incorporates an occlusive dressing with infrared energy has demonstrated in several controlled trials that warm and moist wounds heal faster with less pain.13

Stress Connection

Anxiety and depression can inhibit pain modulation from descending nerve pathways.14 Antianxiety and relaxation medications may modulate the pain. Cognitive-behavioral strategies are part of complementary medicine used to reduce anxiety and promote relaxation. These interventions have been used to treat chronic pain in cancer patients. 

Cognitive behavioral strategies focus on changing the way a person thinks about pain—including its cause, meaning, and treatment effects. The goal is to provide the patient with a sense of personal control over pain by altering the concepts of pain, increasing pain tolerance, and diverting attention away from the pain.

Pain has personal meaning to each person, and only the individual in pain can accurately report his/her pain. It is essential to select pain-intervention strategies with the patient whenever possible. A pain diary is useful for tracking interventions because it provides feedback and a record of what is and what is not working.  

Carrie Sussman, PT, is president of Sussman Physical Therapy Inc/Wound Care Management Services. She can be contacted at busussman@aol.com.

References

1. JCAHO Pain Management Standards Comprehensive Accreditation Manual for Hospitals. Available at: www.jcaho.org Accessed December, 2001.

2. Melzack R. The short-form McGill pain questionnaire. Pain. 1987;30:191-197.

3. Sussman C. Assessment of the skin and wound. In: Sussman C, Bates-Jensen B, ed. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 2nd ed. Gaithersburg, Md: Aspen Publishers; 2001:85-118.

4. Fowler E. “Wound Pain During Dressing Changes.” Paper presented at: How to Decrease Trauma and Pain at Dressing Changes—Satellite Symposium for Advanced Wound Care; April 30, 2001; Las Vegas.

5. Krasner D. Caring for the person experiencing chronic wound pain. In: Krasner D, Rodeheaver G, Sibbald GR, ed. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Orlando, Pa: HMP-Communications; 2001:79-88.

6. Sibbald GR. “Pain In General.” Paper presented at: Satellite Symposium for Advanced Wound Care; April 30, 2001; Las Vegas.

7. Topical Agents or Dressings for Pain in Venous Leg Ulcers. 2001 Cochrane Library.  Available at: www.cochrane.co.uk. Accessed December, 2001.

8. Dykes P, Heggie R, Hill S. Effects of adhesive dressings on the stratum corneum of the skin. Journal of Wound Care. 2001;10:7-10.

9. Julka IS, Alvaro MS, Kumar D. Beneficial effects of electrical stimulation on neuropathic symptoms in diabetes patients. The Journal of Foot and Ankle Surgery. 1998;37:191-193.

10. Kumar D, Alvaro MS, Julka IS, Marshall HJ. Diabetic peripheral neuropathy effectiveness of electrotherapy and amitriptyline for sympotomatic relief. Diabetes Care. 1998;21:1322-1325.

11. Sussman C, Byl N. Electrical stimulation for wound healing. In: Sussman C, Bates-Jensen B, ed. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 2nd ed. Gaithersburg, Md: Aspen Publishers; 2001:497-545.

12. Bates-Jensen B, Edvalson J, Gary DE, Granick MS, Hiltabidel E, Tomaselli N. Management of the wound environment with advanced therapies. In: Sussman C, Bates-Jensen B, ed. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 2nd ed. Gaithersburg, Md: Aspen Publishers; 2001:272-292.

13. Pediani R. What has pain relief to do with acute surgical wound healing?” Available at www.worldwidewounds.com Accessed: March 6, 2001.

14. Galantino ML, Lucci S. Complementary and alternative medicine in the treatment of elderly cancer patients. GeriNotes. 2001;8:17-18.